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Sunday, June 26, 2022

How the Budget can push India’s health system transformation

The expanded ambit of health, as defined in last year’s budget, must continue for aligning other sectors to public health objectives

Written by K Srinath Reddy |
Updated: January 31, 2022 12:12:30 pm
After decades of low government expenditure on health, the Covid pandemic created a societal consensus on the need to strengthen our health system. (Illustration: C R Sasikumar)

A pre-budget assessment, just ahead of the presentation of the budget, is somewhat like a pitch and weather report by a cricket commentator before the start of play. It states how the match might be influenced by the prevailing conditions without showing any certitude that it will actually develop along those lines. So, this piece is more of a prayer than a prediction, hoping that the finance minister will provide the vulnerable health sector the protective “booster” it needs.

After decades of low government expenditure on health, the Covid pandemic created a societal consensus on the need to strengthen our health system. The recommended priorities varied, depending on whether they came from super-specialist doctors arguing for more hospitals and specialists or public health votaries pleading for the expansion and quality enhancement of primary healthcare services and disease surveillance systems. The Fifteenth Finance Commission accepted both viewpoints and recommended greater investment in rural and urban primary care, a nationwide disease surveillance system extending from the block-level to national institutes, a larger health workforce and the augmentation of critical care capacity of hospitals. The Union budget of 2021 reflected these priorities in a proposed Pradhan Mantri Aatmanirbhar Swasth Bharat Yojana (PMASBY) to be made operational over six years, with a budget of Rs 64,180 crore. The Finance Minister also projected a broader vision of health beyond healthcare by merging allocations to water, sanitation, nutrition and air pollution control with the health budget. This resulted in a 137 per cent increase in the allocation to health, though the increase to the health ministry itself was a modest 11 per cent.

In the months that followed the budget, two major health missions were launched, under the Ayushman Bharat umbrella. The Digital Health Mission was launched in September 2021. The Health Infrastructure Mission, launched in October 2021, was a renamed and augmented version of the PMASBY. It aims to create a strong nationwide healthcare and disease surveillance infrastructure, ranging from health and wellness centres (HWCs) and block-level laboratories to more medical colleges and National Institutes of Virology.

These missions join the two other components of Ayushman Bharat launched in 2018. The Comprehensive Primary Health Care (CPHC) component is nested in the National Health Mission (NHM) while the Pradhan Mantri Jan Arogya Yojana (PMJAY) is steered by the National Health Authority (NHA). Bringing these various missions together under the umbrella of Ayushman Bharat will help to create a coherent and connected healthcare delivery system. Primary healthcare services under the CPHC and linkage with water, sanitation, nutrition and pollution control programmes will strengthen the capacity of the health system for health promotion and disease prevention, going beyond disease management. The budget of 2022 must not only fund these missions adequately but indicate how they will link synergically while functioning under different administrative agencies. It will be appropriate for the Health Ministry to be the convening platform, even if the budget lines are separated.

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The NHM received only a 9.6 per cent increase in the 2021 budget. Apart from the capital expenditure on new primary healthcare infrastructure, it needs an increase in its operational budget too, especially as long neglected urban primary healthcare needs urgent attention. PMJAY did not see an increase in allocation last year, because its utilisation for non-Covid care declined sharply in the previous year. The limited number of accredited healthcare facilities in tier-2 and tier-3 hospitals, in many states, is also a limiting factor for the scheme. More importantly, limiting cost coverage to hospitalised care reduces the PMJAY’s capacity to significantly lower out-of-pocket expenditure (OOPE) on health, which is driven mostly by outpatient care and expenditure on medicines. The promise of HWCs to provide essential drugs and diagnostic services — it has been stalled by Covid — needs to be delivered soon if primary care has to become an effective instrument for reducing OOPE.

The Digital Health Mission can enhance efficiency of the health systems in a variety of ways. These include better data collection and analysis, improved medical and health records, efficient supply chain management, tele-health services, support for health workforce training, implementation of health insurance programmes, real time monitoring and sharper evaluation of health programme performance along with effective multi-sectoral coordination. The financing of this mission will be a feature of interest in the budget.

While increased investment in infrastructure and digital health is needed and will be of high value for strengthening our health system, that capacity will be a carriage without wheels if we do not develop a multi-layered, multi-skilled health workforce. We need to increase the numbers and improve the skills of all categories of healthcare providers. While training specialist doctors could take time, the training of frontline workers like Accredited Social Health Activists (ASHAs) and Auxiliary Nurse Midwives (ANMs) can be done in a shorter time. Every village should have two ASHAs and every sub-centre designated as a HWC should have two ANMs as a minimum. Similarly, urban HWCs too should be well staffed. Training and deployment of mid-level health workers in the HWCs too is a priority.

District hospitals need to be upgraded, with greater investment in infrastructure, equipment and staffing. In underserved regions, such district hospitals should be upgraded to become training centres for students of medical, nursing and allied health professional courses. Medical college hospitals too should be strengthened. Public health cadres must be created in every state and training institutions must be established to infuse public health expertise into health programmes. While much of this needs to be done by the states, the Centre should incentivise and support such efforts by the states. Will the Union budget signal such an intent and commitment?

With increased central investment in health, OOPE should continue the declining trend reported in the last reported National Health Accounts (2017-18). However, the decline should not be driven only by an increase in capital expenditure on infrastructure. An increase in current operational expenditure is also needed to improve service delivery and have an early impact on healthcare related financial burden of families. There may be some savings on Covid response this year, especially on the amount allocated to procure vaccines. Those savings must flow to improve non-Covid services which suffered neglect for the past two years. Research and innovation too must see greater investment. The expanded ambit of health, as defined in last year’s budget, must continue for aligning other sectors to public health objectives. The Union budget of 2022 can add further momentum to our health system transformation. I fervently hope it will.

The writer, a cardiologist and epidemiologist, is President, Public Health Foundation of India (PHFI). The views expressed are personal.

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